Tommy Dickinson, 'Curing Queers’: Mental Nurses and their Patients, 1935-74 (Manchester: Manchester University Press 2015) 304pp. £70.00 Hb, £14.99 Pb. ISBN: 978-0-7190-9588-7
'Curing Queers': Mental Nurses and their patients, 1935-74 is a much needed account of the role of 'aversion therapy' utilized as an alternative to imprisonment as punishment for homosexuality during an era when homosexuality, lesbian, bisexual, transgendered and intersex identity, transvestism, paedophilia, necrophilia, bestiality, fetishism, sado-machism, rape, incest, exhibitionism, voyeurism and transsexualism were classed as 'sexual deviant behaviours' and were criminalized under British law. Although treatments were sought for all these behaviours, homosexuality represented the main behaviour to receive treatment (1).
These behaviours are set in the context of relationships between legal, medical, ethical, media, social and cultural establishments during the thirty nine years covered by this book. This era represents a time in British society when attitudes and judgements were more constrained and pessimistic in comparison to present-day standards, with a connecting thread being represented by these various establishments' treatment of homosexuality.
As the author shows, there is a paucity of academic literature on the experiences of individuals who experienced these treatments, a gap which this book aims to remedy. It also makes a contribution to nursing history, particularly the history of mental health nursing.
The author draws on his own personal nursing experiences as a gay mental health nurse and now nursing lecturer. His research included interviewing seventeen mental health nurses who were in hospitals where aversion therapy was utilized, their reactions, thoughts and feelings constituting a sub-culture within the much larger culture of mental health nursing within hospitals, and also eight former patients who received aversion therapy as an alternative to imprisonment. Oral histories are used as the main research tool to examine the experiences and feelings of participants and to address the question of why men received such treatments and the effect on them. (2)
A detailed history of the medicalization of sex is set out in the book together with a history of mental health nursing, both of which provide a foundation for consideration of the topic of the book. This allows both a reader new to the field and the expert to set the book in context and provides additional background material for student nurses, both as regards history of mental health nursing and the legal, socio-cultural theories prevailing at the various epochs with which the book deals.
An outline is given of the oppression of the sexual deviant from 1939-1967 under the auspices of the medical press, news media and the social cultural establishments that were dominant at this time, together with the effect of the Second World War on both homosexuality and nursing. This period brought homosexuality into the public domain in a manner unknown previously, in that homosexual soldiers were now fighting alongside heterosexual men; the book examines how these two groups confronted their new situation. Kinsey’s 1948 study Sexual Behaviour in the Human Male stated that homosexuality was not the rare phenomenon which it was ordinarily considered to be, but a type of behavior which ultimately might involve as much as half of the male population. Much was written in response by the media, legal and sociological establishments in the early 1950s, but following this homosexuality still remained illegal. Political parties took e the matter in hand and thus 'treatments' for homosexuals were born, employing psychological techniques and therapies, for example those of Skinner, Pavlov and Freud.
Aversion therapy was devised. The author describes briefly how this was carried out, although the treatment of aversion therapy in the book is confined to its outcomes and to reactions from the previously mentioned establishments, but more importantly also from its recipients, on whom it had a negative and distressing effect, not unnoticed by a small band of nurses who too felt that aversion therapy was distressing despite the medical press announcing a success.
Nurses came under the auspices of two new legislative frameworks namely the Mental Treatment Act 1930 giving patients greater autonomy and the Mental Health Act 1959 emphasising community care (91). Nursing saw the 'therapeutic' model being introduced in concert with the medical model that had had been the status quo. Nursing practice evolved to deliver more patient-centred care however concurrently treatment became more harrowing, involving procedures such as insulin treatment, electroconvulsive therapy, frontal leucotomy. These somatic (physical) treatments were used on mental health patients by mental health nurses who at the time believed they were doing no harm to the patients, only aiding them back to better health.
Major restructuring of the National Health Act occurred in 1948 (107) whereby the onus of treatment devolved to local Health Boards, alongside regional ones. This omitted, however, psychiatric hospitals which retained their autonomy together with their nursing practices. Nursing divided into general and mental health, with the latter being perceived as not being on par with general nursing, a viewpoint which still prevails today.
Mental health hospitals tended to be situated on the outskirts of towns and previously had functioned as self-sufficient lunatic asylums; the proverb 'out of sight, out of mind' would seem to be applicable. Older buildings were out-dated and mental health nursing still retained a hierarchical regime similar to general nursing whilst suffering from a high staff attrition rate and rising patient numbers. In parallel with this, demand for mental health beds was rising whilst the number of physical beds available for patients were diminishing as wards were closed and patients transferred to newer buildings culminating in large patient numbers with inadequate staffing levels. This continues to be a feature of present day mental health hospitals.
In order to cope with these poor working conditions, mental health nursing evolved its own culture in order to maintain responsible patient care. Mental health nursing culture, as can be observed today, formulated its own rules, regulations, behavior, language, uniform, nursing practice, hierarchy, beliefs and traditions, communication, social structure and norms and thus formed a sub-cultural offshoot from the main nursing establishment.
Nursing standards, culture and patient care varied from hospital to hospital. Autocratic nurses with a penchant for authority coerced both staff and patients, poor nursing standards, sub-standard buildings, pressure to accept increasing patient numbers. Contradictory to this a mental hospital could be a refuge, a workplace or a holiday camp and as such within these hospitals some gay men found a lively atmosphere, a culture and a community to belong to (118).
The author cautions that there is a dearth of literature in nursing textbooks during this period discussing sexual deviations (126) and notes that nurse training promulgated the view that homosexuals were to be viewed with disdain and distaste. Supplementing this was the impact of negative media portrayals, which lead homosexuals to be labelled 'sexual deviants'.
Rising mental health patient numbers drew attention to a need for change and in the mid 1950s community care appeared with the expectation that mental health patients could be discharged from hospital into the community for treatment and hence save the National Health Service from bankruptcy. This together with the introduction of new antipsychotic drugs, integration with other health professionals commenced a slow shift from older nursing practices. Notwithstanding the ethos of mental health nursing still endured.
At this time in mental health nurse training, student nurses accepted what they were told without question due to the dictatorial hierarchy that could be found in nursing, therefore some of the nurses participated in the treatment without consideration as to the benefits to the patients or adverse psychological problems that the patient might suffer as a result of therapy. Authority ruled. No questions were asked, so no answers were required. Doctors had 'exclusive theoretical knowledge' (147). Nursing theory and nursing practice were divergent irrespective of its effect on both nurses and patients. However, for the nurses who participated in aversion therapy their clinical practices had to be acceptable to their moral outlook (151). Current nurse training pursues an opposite direction, following Nursing and Midwifery Council guidelines where students are taught to think, ask, question and in some cases can exercise the option of withdrawing from a clinical procedure on ethical grounds. Nurses now exhibit unconditional positive regard and empathy for patients in their care (155) as advocated by Carl Rogers, who rejected the deterministic nature of both psychoanalysis and behaviourism and maintained that we behave as we do because of the way we perceive our situation. Rogers summed this outlook up though his claim that 'as no-one else can know how we perceive, we are the best experts on ourselves'.
The nurses taking part in aversion therapy had no such guidelines to follow and therefore patient care, judged by today’s nursing standards, was badly compromised. The author notes that nurses were not asked for their opinions or feelings on the therapy and whilst some saw it as part of their nursing duties, others felt aggrieved that they might be inflicting pain and suffering on their patients.
Stanley Milgram (170) supports the view that humans are generally blindly obedient to authority in that they automatically obey what they are told to do without question. One nurse in the book reports that she could remember reading in a newspaper article that 'a doctor had cured a homosexual' and felt that this confirmed that the use of aversion therapy was acceptable (171), something which shows that the media had a voice which the general populous listened to and believed.
In 1967 The Sexual Offenders Act (200) came into effect allowing consensual sex for homosexual men over the age of twenty one. During this time, the media changed its viewpoint on the 'curing' treatments and gradually attitudes towards so-called 'deviance' were becoming less negative. This was also a time when gay men felt that public opinion of them was growing more positive. The 1970s saw the birth of the Gay Liberation Front which demanded equality for homosexuals in law (204), from which Gay Pride emerged in 1972 (204). Public and media opinion was changing. There was also the emergence of anti-establishment thinking, including challenges to the institution of psychiatry (206).
Attitudes to homosexuality were also changing in the USA when in 1973 the American Psychiatric Association, who were responsible for the Diagnostic Statistic Manual, debated the issue of “Should Homosexuality be in the AOA Nomenclature?” (211), with the assistance of the Gay Activist Alliance. Spitzer (212) meanwhile argued that something common to pathologies did not apply to homosexuality in that most patients with disorders listed in the Diagnostic Statistic Manual commonly encountered distress or their conditions interfered with their overall functioning (212). In conjunction to this he also argued that Hooker’s work in comparing functioning levels of homosexuals and heterosexuals was not necessarily impaired therefore homosexuals could not be diagnosed as having a disorder. In 1974 the Diagnostic Statistic Manual version II excluded homosexuality as a diagnosable illness (212).
In parallel to these changes, nurse training was also going through changes and the 1970s saw the introduction of a nurse therapist who practiced behavioural psychotherapy autonomously, dealing with many problems, one being sexual deviation. This role was brought in due to the increasing demand for psychiatric services, freeing up psychiatrists; nurses were cheaper to train than psychiatrists and nursing staff felt removed from their vocation as their roles were being taken over by other health professionals. The role of the Registered Mental Nurse (RMN) was born. Training was improved, and standards established.
The author further affirms that the nurse therapist’s value could be witnessed in the treatment of sexually deviant patients and quotes a study by Marks, Bird and Lindley (217) which concludes that out of ten patients who completed treatment with a nurse therapist, the frequency of the patient's aberrant sexual behavior diminished. However the author goes on to state that due to the small sample number in the study and the possibility that patients could feign their behavior this is an area for which there can be no follow-up results for these patients. Again this supports the author’s statement that there is a dearth of literature available on aversion therapy as the majority of the papers written on the work of nurse therapists were written in the 1970s and the treatments appear to slowly disappear by the mid-late 1970s.
However, nurses were becoming autonomous practitioners and bringing new practices to nursing in assessing, planning, implementing and evaluating the treatment of patients by utilizing personal care plans (Roper, Logan and Tierney) and thus developing a therapeutic relationship with their patients which still continues to this day. This is in stark contrast to the nursing views and practices utilized by the nurses interviewed by the author, who carried out the procedure because they had to and did not question either the rationale or the efficacy of their treatment, or the effects of their actions on the patients.
This is an area of nursing which has been ignored by the literature and as such the author’s work has contributed to fill many voids by its publication. The book itself gives the reader an accurate history of nursing, its role in society, the various establishments and their outlooks on nursing. Nursing is an institutionalised profession in some practice areas. People are resistant to change and today’s nurses find it difficult to question practices that have 'worked' for the past twenty or thirty years. There is change on the way as nursing professionals age and retire; new nurses with new ideas are bringing a freshness into the profession. The work of the author gives an insight into both the nursing profession and the status quo in the period covered by the book. There isn't much literature on nursing and its relationship with the establishments of the era. The author has drawn on a wealth of research works to complete his book and has produced a valuable bibliography. Again due to the nature of the book, many of these papers have not often been cited, making the author's achievement a considerable one.
The book comes under the heading of humanities and nursing history and makes for an excellent reader for all nursing students. It gives student nurses and also research nurses a foundation on which to base their own evidence-based practice, to assess the advantages and disadvantage of some nursing practices, to appreciate the evolution of present day nursing practices and also the source of some nursing ideologies. This is an area which is largely unresearched and as such offers writers, researchers and medical professionals an opportunity to develop the literature, as the author notes. In conclusion, this is an excellent, thoroughly researched, well written work and makes for a very valuable and important contribution to the fields of nursing, literature and science.
Catherine Bryce (BSc), Retired Mental Health Nurse
American Psychiatric Association, Diagnostic Statistical Manual Version II (Arlington 1974) (Seventh Printing)
Evelyn Hooker, “Male Homosexuality in the Rorschach”, Journal of Projective Techniques 21 (1957) 18-31
Alfred Kinsey, Warren Pomeroy and Martin Clyde, Sexual Behaviour in the Human Male (Philadelphia 1948) 23
Isaac Marks, Julian Bird and Peter Lindley Peter Behavioural Nurse Therapists. British Journal of Psychiatrists 135 (1979) 27
Stanley Milgram, Obedience to Authority: An Experimental View (New York 1969)
Saul McLeod, “Carl Rogers” Simply Psychology. http://www.simplypsychology.org/carl-rogers.html (2007, updated 2014) Web 24 July 2016
Mental Health Act 1959 (91)
National Health Act 1948 (107)
Nursing and Midwifery Council. “Code of Practice” https://www.nmc.org.uk/standards/code/read-the-code-online/ “Introduction Make sure that people’s physical, social and psychological needs are assessed and responded to”. Nursing and Midwifery Council. (29 January 2015) Effective from 31 March 2011. Web 19 July 2016
Roper, Nancy, Logan Winifred and Tierney Alison “Chapter Three: Transcultural nursing care of adults” http://www2.rcn.org.uk/development/learning/transcultural_health/transcultural/adulthealth/sectionthree Royal College of Nursing (2004) Web 11 July 2016